16 July 2006

As an ER doc, you are supposed to really live for the bad cases: the crashing patient, shocking the heart, intubating, flinging drugs like an ubermensch, heroically stamping out disease and pulling lives back from the abyss. You're supposed to ride the adrenaline as naturally and instinctively as the surfer rides the wave. Our friend charitydoc perhaps epitomizes this unselfconscious id-like personality that is supposed to be the fundamental characteristic of the ER doc. And truth be told, it's not all myth -- most of us in the ED do get off on the excitement and adrenaline.

But sometimes, you're just not up for it. You're tired, or got in a fight with the wife, or for whatever reason, just can't really summon the enthusiasm for the event. But that doesn't stop them from coming in, does it? Much though you might like to close the doors and turn off the lights, the ambulances still bring you the business. So there's nothing for it but to put on your game face, stand up straight, and head into the room as the paramedics bring in the next customer. It's not too hard, really. After so many years, it's almost a pavlovian response.

So tonight, near the end of my shift, after I had already seen 30 patients in 9 hours, which is unusually busy even for me, the radio crackled to life. The report started a buzz at the nursing station:

Oh, this does not sound good. More details came over: Baby, just a few hours old, umbilical cord still attached. Found in a local pond inside a white plastic garbage bag tied with a knot. Someone who lives on the pond heard some commotion and managed to fish the kid out and call 911.

So we get ready, call NICU, I review the neonatal resuscitation algorithm in my mind as we pull out the warmer and await the medics' arrival. I am not looking forward to this. I can see it now, a cold blue floppy baby. Will they have a line? I can't remember the last umbilical line I started. They probably have an airway already -- the local EMS is very good at that. These are always grim. I wonder in advance how long we will have to go through the motions before we can in decency call it.

To my surprise, the medics come in with a pink, squalling infant. Cold, to be sure, with a rectal temp of 83 degrees. But otherwise fine, with a brand new clamp on the ragged stump of umbilicus, vigorous, and warming up rapidly. Glucose good at 96. The NICU team shows up moments thereafter, and in no time flat, the kid is lined, labbed, x-rayed, and bustled off to the NICU. Babies withstand hypothermia wonderfully; the plastic bag probably prevented drowning and helped the kid float, while the cold water initiated the dive reflex and help put his brain into hibernation. Amazing.

So I wander back out to the near-desolate ED and pick up my stack of incomplete charts. It's funny, sometimes as an ER doc you feel a little cheated when you have a crash case like this that turns out to be a false alarm. You get your game face on for nothing, as it were. But in this case, I feel only relief. Relief that I didn't have to go through the excruciating dance that precedes the formal declaration of a baby's death. Relief that the child is well. Relief that some mother, who in her desperation and fear threw away her newborn baby, is not now a murderer. I wonder if they'll find her? The police have been here and the media have already called. I can't help but feel bad for her, even though she did a monstrous thing. What sort of straits must she be in to try to drown her infant? I cannot imagine.

yup ... know that feeling so well. our ER is going thru a huge building campaign...everything is in disarray ... had a major cycle accident last week ... gonna be fun...everything busted on the Left... and flight got there just after the patient did...so we didn't get to play at all!!!!

just as well, since we're still not used to where everything is ... but a disappointment on some level.

Just a minor correction - Temp on arrival was 88, not 83. And also for anyone out there considering not keeping their child once born: if you drop off your baby at the hospital you won't be charged with abandonment and prosecuted by the authorities.

Just found this blog: I think I have a very personal connection with the area and very possibly with you. Maybe you came there after I left: I don't remember any Karate-kicking ER docs. Anyway, nice post; reminds me of the "exsanguination and evisceration" call we took in the ER in training, to see the patient wheeled down the hall laughing and joking. Nice blog. I'll keep an eye out.

From the perspective of a very new nursing student in the ER, I really love your posts.

And I really liked that you put in a bit about the mother - and what kind of horrible situation had led her to throw away her baby. In my short time in the ER, I've seen some really repugnant patients, and in the back of my mind, I'm constantly wondering, "How the hell did you get this way?"

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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